Impact of Lifestyle Modification to Reduce Cardiovascular Disease Event Risk of High Risk Patients with Low Levels of HDL C

Impact of Lifestyle Modification to Reduce Cardiovascular Disease Event Risk of High Risk Patients with Low Levels of HDL C Thomas P. Bersot, M.D., Ph.D. Gladstone Institute of Cardiovascular Disease University of California San Francisco 4 th Annual Central California Cardiometabolic Risk Symposium Fresno, CA March 17, 2012

Disclosures Consulting, speaking, advisory board membership and stock ownership Abbott, AstraZeneca, Merck, Roche and GSK

Lifetime Risk From Age 40 of Developing CHD, Cerebrovascular Disease or CHF Men 2/3 Women 1/2 D. Lloyd Jones, Framingham Heart Study Data Heart Disease and Stroke Statistics 2012 Update, p. e22. American Heart Association. Circulation 125: e2 e220 (2012)

CHD Mortality and Sudden Cardiac Death* (2008) Total CHD Mortality = 405,309 Sudden Cardiac Death (SCD) = 121,593 (30 percent of CHD mortality) Primary Prevention Sudden Cardiac Deaths = 86,688 (19% of total CHD deaths; 53% of all sudden deaths) *Circulation 125: e2 e220 (2012)

CHD Mortality and Sudden Cardiac Death* (2008) Total CHD Mortality = 405,309 Sudden Cardiac Death (SCD) = 121,593 (30 percent of CHD mortality) Primary Prevention Sudden Cardiac Deaths = 64,444 (16% of total CHD deaths; 53% of all sudden deaths) *Circulation 125: e2 e220 (2012)

CHD Mortality and Sudden Cardiac Death* (2008) Total CHD Mortality = 451,326 Sudden Cardiac Death (SCD) = 121,593 (30 percent of CHD mortality) Primary Prevention SCD = 64,444 (16% of total CHD deaths; 53% of all SCD) 64,444 SCD / 610,000 first MIs in 2008 means that one of every nine first MIs is a sudden death. *Circulation 125: e2 e220 (2012)

CHD Mortality and Sudden Cardiac Death* (2008) Total CHD Mortality = 405,309 Sudden Cardiac Death (SCD) = 121,593 (30 percent of CHD mortality) Primary Prevention SCD = 64,444 (16% of total CHD deaths; 53% of all SCD) 64,444 SCD / 610,000 first MIs in 2008 means that one of every nine first MIs is a sudden death. These patients never become secondary prevention patients. *Circulation 125: e2 e220 (2012)

Prevention of First Events: Promoting Cardiovascular Health Secondary prevention for patients with clinical CVD caused by atherosclerosis Primary prevention for patients with adverse levels of risk factors Primordial prevention* promoting cardiovascular health of the entire population by avoiding adverse levels of risk factors * Circulation 121: 586 613 (2010)

AHA 2020 National Goal for Cardiovascular Health Promotion of the Population of the USA* 20 percent improvement in the prevalence of healthy behaviors and CVD health risk factors compared to prevalence existing in the 2005 2006 NHANES survey *AHA Special Report. Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction. The American Heart Association s Strategic Impact Goal Through 2020 and Beyond. Circulation 121: 586 613 (2010)

Definition of Ideal Cardiovascular Health Current smoking: Never or quit 12 mo ago BMI < 25 kg/m 2 Physical activity: 150 min/wk moderate intensity or 75 min/wk vigorous intensity Healthy diet score: 4 5 Components Total cholesterol:< 200 mg/dl(no drug Rx) BP: <120/<80 mm Hg (no drug Rx) Fasting plasma glucose: <100 mg/dl Circulation 121: 586 613 (2010)

Definition of Ideal Cardiovascular Health Current smoking: Never or quit 12 mo ago BMI < 23 kg/m 2 (some Asian ethnic groups)* Physical activity:150 min/wk moderate intensity or 75 min/wk vigorous intensity Healthy diet score: 4 5 Components Total cholesterol:< 200 mg/dl(no drug Rx) BP: <120/<80 mm Hg (no drug Rx) Fasting plasma glucose: <100 mg/dl *Lancet 363: 157 163 (2004) Circulation 121: 586 613 (2010)

Definition of Ideal Cardiovascular Health Current smoking: Never or quit 12 mo ago BMI < 25 kg/m 2 or < 23 kg/m 2 Physical activity: 150 min/wk moderate intensity or 75 min/wk vigorous intensity Healthy diet score: 4 5 Components Total cholesterol:< 200 mg/dl(no drug Rx) BP: <120/<80 mm Hg (no drug Rx) Fasting plasma glucose: <100 mg/dl Circulation 121: 586 613 (2010)

Five Primary Components of Dietary Goals* Fruits and vegetables: 4.5 cups per day Fish: two 3.5 oz servings per week (preferably oily fish) Fiber rich whole grains (1.1 g of fiber per 10 g of carbohydrate): three 1 oz equivalent servings per day [servings = ½cup cooked rice/pasta; 1 slice bread; 1 1 oz dry cereal] Sodium: 1,500 mg per day Sugar sweetened beverages: 450 kcal (36 oz) per week. * Circulation 121: 586 613 (2010)

Three Secondary Components of Dietary Goals Nuts (1/3 cup), legumes (1/2 cup), and seeds (2 tbsp): total of 4 servings per week Processed meats: none to 2 servings per week Saturated fat: 7% of total energy intake * Circulation 121: 586 613 (2010)

Definition of Ideal Cardiovascular Health Current smoking: Never or quit 12 mo ago BMI < 25 kg/m 2 or < 23 kg/m 2 Physical activity: 150 min/wk moderate intensity or 75 min/wk vigorous intensity Healthy diet score: 4 5 Components Total cholesterol < 200 mg/dl (no drug Rx) BP <120/<80 mm Hg (no drug Rx) Fasting plasma glucose < 100 mg/dl Circulation 121: 586 613 (2010)

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Incidence Rate of Cardiovascular Disease According to the Number of Ideal Health Behaviors and Health Factors (Atherosclerosis Risk in Communities, 1987 2007)* Factors total chol blood pressure fasting glucose (smoking, BMI, physical activity, healthy diet score) *FOLSOM AR ET AL., J AM COLL CARDIOL 57: 1690 6 (2010)

Benefit of Drug Therapy and Lifestyle Changes on CHD Event Rates from 1980 2000* Reduction in CHD events per 100,000: 1980 2000 Men, 543 267 ( 51%) Women, 263 134 ( 49%) CHD Deaths in 2000: 337,658 *Ford ES et al., New Engl J Med 356: 2388 98 (2007)

Benefit of Drug Therapy and Lifestyle Changes on CHD Event Rates from 1980 2000* Reduction in CHD events per 100,000: Men, 543 267 ( 51%) Women, 263 134 ( 49%) Expected Deaths in 2000 at 1980 CHD Rate: 337,658 679,403 ( 50%) What accounts for the 50% lower CHD event and death rates from 1980 to 2000? *Ford ES et al., New Engl J Med 356: 2388 98 (2007)

Benefit of Drug Therapy and Lifestyle Changes on CHD Death Rates from 1980 2000* What accounts for the reductions in CHD death rates from 1980 to 2000? New therapies and 2 prevention, 47% statin drug Rx, 4.9%; anti HTN drug Rx, 7.0% Population risk factor changes, 44% total chol, 219 206 mg/dl, 24% SBP, 129 124 mm Hg, 20% *Ford ES et al., New Engl J Med 356: 2388 98 (2007)

Benefit of Drug Therapy and Lifestyle Changes on CHD Death Rates from 1980 2000* What accounts for the reductions in CHD death rates from 1980 to 2000? New therapies and 2 prevention, 47% statin drug Rx, 4.9% anti HTN drug Rx, 7.0% Population risk factor changes, 44% total chol, 219 206 mg/dl, 24% SBP, 129 124 mm Hg, 20% *Ford ES et al., New Engl J Med 356: 2388 98 (2007) Lifestyle Benefits (not drug mediated)

Benefit of Lifestyle Changes on CHD Death Rates from 1980 2000* Population risk factor changes, accounted for 44% of the lower death rate in 2000 total chol, 219 206 mg/dl, 24% SBP, 129 124 mm Hg, 20% Smoking prevalence (%), 36 25, 12% Physical inactivity (%), 30 27, 5% BMI (kg/m 2 ), 25.6 28.2, 8% Diabetes prevalence(%), 6.5 9.4, 10% *Ford ES et al., New Engl J Med 356: 2388 98 (2007)

Benefit of Lifestyle Changes in Risk Factors on CHD Death Rates from 1980 2000* Improvements prevented 209,000 deaths total chol, 219 206 mg/dl, 24% SBP, 129 124 mm Hg, 20% Smoking prevalence (%), 36 25, 12% Physical inactivity (%), 30 27, 5% Offset by an increase of 59,370 deaths BMI (kg/m 2 ), 25.6 28.2, 8% Diabetes prevalence(%), 6.5 9.4, 10% *Ford ES et al., New Engl J Med 356: 2388 98 (2007)

Benefit of Lifestyle Changes in Risk Factors on CHD Death Rates from 1980 2000* Improvements prevented 209,000 deaths due to reductions of total chol, systolic blood pressure, smoking prevalence and increased physical activity Offset by an increase of 59,370 deaths The increased prevalence of overweight/obesity and diabetes negated 28%** of the reduced death benefit associated with improvements in lifestyle. *Ford ES et al., New Engl J Med 356: 2388 98 (2007); ** 59,370 / 209,000 = 0.28

How Will YOU Promote the 2020 AHA Lifestyle Goals Among YOUR Patients?

See diet pages (last 4 pages of this handout)

Take Home Message Lifestyle change is requisite for CVD prevention at ALL levels of risk. Specific evidence based behaviors include: Eating fish twice or more a week 1000 mg EPA + DHA daily for highest risk Alpha linolenic acid as preferred oil Walking 30 40 min/day 5 6 days/week 10 15 lb weight loss plus walking as above to avert diabetes in patients with impaired fasting glucose Make plans with patients to implement change.